Joint Commission International Accreditation Standards For .

Joint Commission InternationalAccreditation Standards forHospitalsIncluding Standards for Academic Medical Center Hospitals6th Edition Effective 1 July 2017

Section I:Accreditation ParticipationRequirements

AccreditationParticipationRequirements (APR)Requirement: APR.1The hospital meets all requirements for timely submissions of data and information to Joint CommissionInternational (JCI).Requirement: APR.2The hospital provides JCI with accurate and complete information throughout all phases of the accreditationprocess.Requirement: APR.3The hospital reports within 30 days of the effective date of any change(s) in the hospital’s profile (electronicdatabase) or information provided to JCI via the E-App before and between surveys.Requirement: APR.4The hospital permits on-site evaluations of standards and policy compliance or verification of quality and safetyconcerns, reports, or regulatory authority sanctions at the discretion of JCI.Requirement: APR.5The hospital allows JCI to request (from the hospital or outside agency) and review an original or authenticatedcopy of the results and reports of external evaluations from publicly recognized bodies.Requirement: APR.6Currently not in effect.Requirement: APR.7The hospital selects and uses measures as part of its quality improvement measurement system.3

Joint Commission International Accreditation Standards for Hospitals, 6th EditionRequirement: APR.8The hospital accurately represents its accreditation status and the programs and services to which JCIaccreditation applies. Only hospitals with current JCI accreditation may display the Gold Seal.Requirement: APR.9Any individual hospital staff member (clinical or administrative) can report concerns about patient safety andquality of care to JCI without retaliatory action from the hospital.To support this culture of safety, the hospital must communicate to staff that such reporting is permitted. Inaddition, the hospital must make it clear to staff that no formal disciplinary actions (for example, demotions,reassignments, or change in working conditions or hours) or informal punitive actions (for example,harassment, isolation, or abuse) will be threatened or carried out in retaliation for reporting concerns to JCI.Requirement: APR.10Translation and interpretation services arranged by the hospital for an accreditation survey and any relatedactivities are provided by qualified translation and interpretation professionals who have no relationship to thehospital.Qualified translators and interpreters provide to the hospital and JCI documentation of their experience intranslation and interpretation. The documentation may include, but is not limited to, the following: Evidence of advanced education in English and in the language of the host hospital Evidence of translation and interpretation experience, preferably in the medical field Evidence of employment as a professional translator or interpreter, preferably full-time Evidence of continuing education in translation and interpretation, preferably in the medical field Membership(s) in professional translation and interpretation associations Translation and interpretation proficiency testing results, when applicable Translation and interpretation certifications, when applicable Other relevant translation and interpretation credentialsIn some cases, JCI can provide organizations with a list of translators and interpreters that meet therequirements listed above.Requirement: APR.11The hospital notifies the public it serves about how to contact its hospital management and JCI to reportconcerns about patient safety and quality of care.Methods of notice may include, but are not limited to, distribution of information about JCI, includingcontact information in published materials such as brochures and/or posting this information on the hospital’swebsite.The following link is provided to report a patient safety or quality of care concern to als seeking initial accreditation should be prepared to discuss their plan on how compliance with thisAPR will be achieved once accredited.4

Joint Commission International Accreditation Standards for Hospitals, 6th EditionRequirement: APR.12The hospital provides patient care in an environment that poses no risk of an immediate threat to patientsafety, public health, or staff safety.5

Section II:Patient-CenteredStandards

International PatientSafety Goals (IPSG)StandardsGoal 1: Identify Patients CorrectlyIPSG.1The hospital develops and implements a process to improve accuracy of patient identifications. 𝖯Goal 2: Improve Effective CommunicationIPSG.2The hospital develops and implements a process to improve the effectiveness of verbal and/ortelephone communication among caregivers. 𝖯IPSG.2.1The hospital develops and implements a process for reporting critical results ofdiagnostic tests. 𝖯IPSG.2.2The hospital develops and implements a process for handover communication. 𝖯Goal 3: Improve the Safety of High-Alert MedicationsIPSG.3The hospital develops and implements a process to improve the safety of high-alert medications. 𝖯IPSG.3.1The hospital develops and implements a process to manage the safe use ofconcentrated electrolytes. 𝖯Goal 4: Ensure Safe SurgeryIPSG.4The hospital develops and implements a process for the preoperative verification and surgical/invasive procedure site-marking. 𝖯IPSG.4.1The hospital develops and implements a process for the time-out that is performedimmediately prior to the start of the surgical/invasive procedure and the sign out thatis conducted after the procedure. 𝖯Goal 5: Reduce the Risk of Health Care-Associated InfectionsIPSG.5The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk ofhealth care–associated infections. 𝖯Goal 6: Reduce the Risk of Patient Harm Resulting from FallsIPSG.6The hospital develops and implements a process to reduce the risk of patient harm resulting fromfalls for the inpatient population. 𝖯IPSG.6.1The hospital develops and implements a process to reduce the risk of patient harmresulting from falls for the outpatient population. 𝖯7

Access to Care andContinuity of Care(ACC)StandardsScreening for Admission to the HospitalACC.1Patients who may be admitted to the hospital or who seek outpatient services are screened toidentify if their health care needs match the hospital’s mission and resources. 𝖯ACC.1.1Patients with emergent, urgent, or immediate needs are given priority for assessmentand treatment.ACC.1.2The hospital considers the clinical needs of patients and informs patients when thereare unusual delays for diagnostic and/or treatment services. 𝖯Admission to the HospitalACC.2The hospital has a process for admitting inpatients and for registering outpatients. 𝖯ACC.2.1Patient needs for preventive, palliative, curative, and rehabilitative services areprioritized based on the patient’s condition at the time of admission as an inpatient tothe hospital.ACC.2.2At admission as an inpatient, the patient and family receive education and orientationto the inpatient ward, information on the proposed care and any expected costs forcare, and the expected outcomes of care.ACC.2.2.1 The hospital develops a process to manage the flow of patientsthroughout the hospital. 𝖯ACC.2.3Admission to departments/wards providing intensive or specialized services isdetermined by established criteria. 𝖯ACC.2.3.1 Discharge from departments/wards providing intensive or specializedservices is determined by established criteria. 𝖯Continuity of CareACC.3The hospital designs and carries out processes to provide continuity of patient care services in thehospital and coordination among health care practitioners. 𝖯ACC.3.1During all phases of inpatient care, there is a qualified individual identified asresponsible for the patient’s care. 𝖯ACC.3.2Information related to the patient’s care is transferred with the patient.Discharge, Referral, and Follow-UpACC.48There is a process for the referral or discharge of patients that is based on the patient’s health statusand the need for continuing care or services. 𝖯

Joint Commission International Accreditation Standards for Hospitals, 6th EditionACC.4.1Patient and family education and instruction are related to the patient’s continuingcare needs.ACC.4.2The hospital cooperates with health care practitioners and outside agencies to ensuretimely referrals.ACC.4.3The complete discharge summary is prepared for all inpatients.ACC.4.3.1 Patient education and follow-up instructions are given in a form andlanguage the patient can understand.ACC.4.3.2 The medical records of inpatients contain a copy of the dischargesummary. 𝖯ACC.4.4The records of outpatients requiring complex care or with complex diagnoses containprofiles of the medical care and are made available to health care practitionersproviding care to those patients. 𝖯ACC.4.5The hospital has a process for the management and follow-up of patients who notifyhospital staff that they intend to leave against medical advice.ACC.4.5.1 The hospital has a process for the management of patients who leave thehospital against medical advice without notifying hospital staff.Transfer of PatientsACC.5Patients are transferred to other organizations based on status, the need to meet their continuingcare needs, and the ability of the receiving organization to meet patients’ needs.ACC.5.1The referring hospital develops a transfer process to ensure that patients are transferredsafely.ACC.5.2The receiving organization is given a written summary of the patient’s clinicalcondition and the interventions provided by the referring hospital.ACC.5.3The transfer process is documented in the patient’s medical record. 𝖯TransportationACC.6The hospital’s transportation services comply with relevant laws and regulations and meetrequirements for quality and safe transport. 𝖯9

Patient and FamilyRights (PFR)StandardsPFR.1PFR.2The hospital is responsible for providing processes that support patients’ and families’ rights duringcare. 𝖯PFR.1.1The hospital seeks to reduce physical, language, cultural, and other barriers to accessand delivery of services.PFR.1.2The hospital provides care that supports patient dignity, is respectful of the patient’spersonal values and beliefs, and responds to requests for spiritual and religiousobservance.PFR.1.3The patient’s rights to privacy and confidentiality of care and information arerespected. 𝖯PFR.1.4The hospital takes measures to protect patients’ possessions from theft or loss.PFR.1.5Patients are protected from physical assault, and populations at risk are identified andprotected from additional vulnerabilities.Patients are informed about all aspects of their medical care and treatment and participate in careand treatment decisions. 𝖯PFR.2.1The hospital informs patients and families about their rights and responsibilities torefuse or discontinue treatment, withhold resuscitative services, and forgo or withdrawlife-sustaining treatments. 𝖯PFR.2.2The hospital supports the patient’s right to assessment and management of pain andrespectful compassionate care at the end of life.PFR.3The hospital informs patients and families about its process to receive and to act on complaints,conflicts, and differences of opinion about patient care and the patient’s right to participate in theseprocesses. 𝖯PFR.4All patients are informed about their rights and responsibilities in a manner and language they canunderstand.General ConsentPFR.5General consent for treatment, if obtained when a patient is admitted as an inpatient or is registeredfor the first time as an outpatient, is clear in its scope and limits. 𝖯Informed ConsentPFR.5.110Patient informed consent is obtained through a process defined by the hospital andcarried out by trained staff in a manner and language the patient can understand. 𝖯